Provider Demographics
NPI:1043372519
Name:LIGHTBODY, THERESA (ARNP)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:LIGHTBODY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 SW 87TH AVE
Mailing Address - Street 2:SUITE C-340
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3570
Mailing Address - Country:US
Mailing Address - Phone:305-595-0109
Mailing Address - Fax:305-595-7092
Practice Address - Street 1:7800 SW 87TH AVE
Practice Address - Street 2:SUITE C-340
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3570
Practice Address - Country:US
Practice Address - Phone:305-595-0109
Practice Address - Fax:305-595-7092
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3239262363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP3239262OtherARNP LICENSE
FLY045GZMedicare ID - Type Unspecified